“I asked Mr. Tarala if he was offering his resignation because he had done something wrong and he replied that he had been working long hours and probably did some things that he should not have done,” Guenther stated in his memo.

Police were called in and laid criminal charges against Tarala.

The prosecution ultimately failed, in part because Smith had died in the interim and the judge would not allow her written allegations as evidence because cross-examination was not possible.

Ten days after Guenther’s report to his superior, Smith was put on a plane to a facility in Montreal.

Guenther testified the alleged assault was the “precipitating incident” for the transfer but the transfer assessment makes no mention of it.

Now retired, Guenther told the inquest Smith didn’t seem to care she could be doing permanent harm to herself by tying ligatures around her neck.

He choked up and needed a moment to compose himself as he testified that he was present when a nurse explained to Smith that oxygen deprivation could kill brain cells or damage her eyes.

Smith’s response, Guenther said, was: “Whatever.”

Guenther, who was effectively warden at RPC, said the teen presented a level of intensity and sustained level of self-harm that was unlike anything he had ever experienced.

Within days of her arrival from Nova Institution in Truro, N.S., she started tying ligatures around her neck, sparking a cycle of forceful interventions.

The self-harming behaviour appeared to be an attention-getting device, so Guenther’s directive was for staff to be matter-of-fact in removing the ligatures.

“Go out and save life, but save the drama,” he said he told them.

Guenther also discussed his opposition to “very invasive” cavity searches given Smith’s creativity and ingenuity in obtaining ligatures and hiding them in her body cavities.

“You could conceivably do this many times a day,” Guenther testified. “The futility of this occurred to me.”

While guards used inappropriate force on Smith on several occasions, he said, at other times the teen would readily admit they were right to be forceful.

“I kicked the officer. Yes I assaulted her. They did what they needed to do so I would stop,” Smith told Guenther after one of the incidents in which she kicked, bit or spat on guards.

Smith was sent to the custodial forensic psychiatry facility operated by Correctional Service Canada in December 2006 because authorities at the prison in Truro believed she would get intensive mental health treatment there.

RPC is the only federal correctional facility that can take female inmates with mental health issues.

The inquest has previously heard that staff at Nova couldn’t cope with her disruptive, self-harming behaviour.

After more than a dozen further transfers, Smith, 19, of Moncton, N.B., choked herself to death in her segregation cell in Kitchener, Ont., in October 2007 as guards — under orders not to intervene — stood by and watched.